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Iran Red Crescent Med J. In Press(In Press):e68913. doi: 10.5812/ircmj.68913.

Published online 2018 December 17. Research Article

Comparing the Effectiveness of Vestibular Rehabilitation and Frenkel

Exercise on Fatigue Reduction in Patients with Multiple Sclerosis: A
Randomized Controlled Trial
Fatemeh Karami 1 , Ardashir Afrasiabifar 1, * and Shahla Najafi Doulatabad 1
1
Yasuj University of Medical Sciences, Yasuj, Iran
*
Corresponding author: Yasuj University of Medical Sciences, Yasuj, Iran. Email: afrasiabifar.ardashir@yums.ac.ir

Received 2018 March 26; Revised 2018 October 09; Accepted 2018 October 11.

Abstract

Background: Fatigue is one of the most common complaints in people with Multiple Sclerosis (MS). The use of non-
pharmacological interventions, such as exercise, may be effective in reducing fatigue in these patients.
Objectives: This study aimed to evaluate the effect of vestibular rehabilitation and Frenkel exercise on fatigue in patients with
multiple sclerosis.
Methods: This study was a controlled randomized clinical trial. Seventy-five patients, who had medical records at the society of
special diseases of the Yasuj University of Medical Sciences, Iran, in 2016, were randomly assigned to three groups, namely, vestibular
rehabilitation, Frenkel, and control. The program lasted for 12 weeks (three sessions per week). Fatigue was measured by the Fatigue
Impact Scale (FIS) before the intervention, and after that, at six and twelve weeks after the initiation of intervention.
Results: The mean score of fatigue in both experimental groups was decreased in a statistically significant manner after the end of
the exercises, whereas it was increased in the control group. The reduction in fatigue was statistically significant in the vestibular
rehabilitation exercise in comparison with the Frenkel exercise. The total fatigue in the vestibular rehabilitation group at six and
twelve weeks after the intervention was -14.1 and -33.1, respectively, in comparison with before the interventions yet in the Frenkel
group it was reported as -8 and -17.9, respectively. The comparison of the FIS subscales showed that there was a difference between
the vestibular rehabilitation and Frenkel group in both the FIS physical (P = 0.001) and the psychosocial subscales (P = 0.01), yet no
difference was observed between the two groups in the FIS cognitive subscale (P = 0.1) at twelve weeks after the intervention.
Conclusions: Both vestibular rehabilitation and Frenkel exercise could reduce fatigue in MS patients, however, vestibular rehabili-
tation was more effective compared to the Frenkel exercise in reducing fatigue.

Keywords: Exercise, Fatigue, Frenkel, Multiple Sclerosis, Rehabilitation, Vestibular

1. Background non-pharmacological interventions are considered as ap-

Fatigue is defined as a decrease in physical and/or men-
tal performance (1). It is one of the common complaints of
patients with Multiple Sclerosis (MS). Seventy-four percent
of such patients suffer from severe fatigue (2) and 80% ex-
perience fatigue in the first year of the onset of MS (3). Fa-
tigue may be the result of hypothalamic-pituitary-adrenal
axis changes, immune dysfunctions, and impaired nerve
conduction (4). Fatigue can affect all aspects of quality of
life (5) of MS patients.
Some medications, such as Amantadine, Levocarni-
tine, Glatiramer acetate (6), and Natalizumab (7) may
be useful in reducing fatigue of MS patients; however,
there are no known drugs with fewer side effects that
can completely prevent or improve fatigue. Therefore,
proaches for fatigue management (8). The review of the
literature shows that biofeedback (9) and cognitive behav-
ioral therapy (10) have been used to reduce fatigue in MS
patients.
Exercise therapy is a non-pharmacological method,
whose impact on MS symptoms has been investigated in
previous studies (11, 12). It was previously thought that exer-
cise leads to worsening of MS symptoms, in contrast, how-
ever, recent studies have revealed evidence to support that
exercise is helpful for MS patients. Exercise can improve
balance (13), mental functioning (14), and quality of life
(15). Although the benefits of exercise are clear, some stud-
ies have shown that MS patients have a lower tendency to
engage in an exercise in comparison with patients of other

Copyright © 2018, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License
(http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly
cited
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Karami F et al.
chronic diseases (16, 17). There is also no consensus about
the effects of exercise therapy on fatigue in MS patients.
Some studies have reported the positive effects of exercise
on fatigue (18, 19); however, the ineffectiveness of exercise
on fatigue has also been reported in some studies (20).
There are different therapeutic exercises, among
which simple exercises, such as vestibular rehabilitation
and Frenkel exercise, should be noted. Vestibular reha-
bilitation exercise compensates defects in the vestibular
system via adaptation, habituation, and substitution (21),
and thereby improves the performance of the cerebellar
and visual system, and ultimately, the individual’s balance
(22). In one study, balance improvement was reported
after patients with unilateral vestibular deficit underwent
a vestibular rehabilitation exercise (23). Frenkel is a type
of aerobic exercise that corrects motor defects in the
cerebellum, stimulate voluntary movement control, and
helps the Central Nervous System (CNS) compensate the
loss of the kinesthetic sense or the body sensory infor-
mation (knowing where it is in space) (24). It includes a
series of slow, repetitious motions that are performed in
different positions when lying down, sitting, and stand-
ing, and these programs target the cerebellum as the
main center for controlling balance, and finally lead to
an improvement in balance. In a case report study, the
improvement of balance in a patient diagnosed with
acquired immunodeficiency syndrome, associated with
progressive multifocal leukoencephalopathy and neuro-
toxoplasmosis, was reported after a year of performing
Frenkel exercise (25). Since fatigue is considered as the
predictor of maintenance of somatic balance (26), it seems
that patients, who attempt to maintain balance during the
performance of tasks may experience significant levels of
fatigue (27). Therefore, balance improvement, following
these exercises, may be useful in reducing fatigue.
Since the prevalence of fatigue is high in MS patients
and fatigue may be a sign of imbalance (28), and because
of the lack of consensus on the impact of therapeutic exer-
cises on fatigue, and the limitation of evidence indicating
the effectiveness of intervention using vestibular rehabili-
tation and Frenkel exercise on fatigue in MS patients, fur-
ther studies in this area are needed.
2. Objectives
The main question of this study is whether perform-
ing vestibular rehabilitation and Frenkel exercise could re-
duce fatigue as well as if there is any difference between
the effectiveness of these exercises. This study was con-
ducted to compare the effect of vestibular rehabilitation,
and Frenkel exercise on fatigue in MS patients.
2 Iran Red Crescent Med J. In Press(In Press):e68913.
3. Methods
3.1. Patients
This study involved a controlled randomized clinical
trial. The population of the study included MS patients,
who had medical records at the Society of Special Diseases
of Yasuj University of Medical Sciences, Iran, during the
year 2016. The inclusion criteria for patients consisted of
a confirmed diagnosis of disease by a neurologist, pass-
ing at least six months from the onset, being in the re-
mission period, being between the ages of 15 and 55 years,
ability to stand for 30 seconds, and to walk a distance of
six meters without any assistance, to have a Fatigue Im-
pact Scale (FIS) score from 54 to 107, no history of participa-
tion in a rehabilitation program within the last six months,
and no diseases other than MS. Furthermore, the patients
were evaluated by the Berg Balance Scale (BBS) to deter-
mine the existence of imbalance in these patients before
the intervention. The patients, who had a BBS score from
21 to 40 or a moderate imbalance, were selected. Refus-
ing to continue participation or inability to participate in
exercises, and the relapse of diseases during the period
of study were considered as exclusion criteria. Written
informed consent was obtained before starting the exer-
cises. Emphasis was placed on the confidentiality of infor-
mation, and the patient’s ability to exit at any stage dur-
ing the study. The study was approved by the Research
Ethics Committee of Yasuj University of Medical Sciences
(ETH number: ir.yums.REC.1394.180), and was registered on
site with the Iranian Registry Clinical Trials with IRCT, num-
ber; IRCT2016031527063N1 (29).
From the 120 available patients, a total of 75 eligible pa-
tients with multiple sclerosis, who met the inclusion crite-
ria, were selected using the convenience sampling method
and were allocated to two groups, vestibular rehabilita-
tion, and Frenkel exercises, as well as a control group,
based on block randomization. The sample size was cal-
culated based on prior studies considering 95% confidence
level, 80% power, S1 = 1.3, S2 = 1.4, and µ1 - µ2 = 2.5. The below
formula was used:
h i
S12 + S22


2 Z1− α2 + Z1−β
n=
(µ1 − µ2 )2
The randomization process was performed by a per-
son, who was not involved in any part of the study proce-
dure. The groups were randomly labeled (A = vestibular
rehabilitation group, B = Frenkel group, and C = control
group). Since there were three groups in this study, the to-
tal number of blocks was six in blocks of three. Random
sampling with replacement was made from these blocks.
During the intervention, one patient from the Frenkel ex-
ercise group dropped out due to disease relapse.
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Karami F et al.
Furthermore, one patient from the vestibular rehabil-
itation group and one patient from the Frenkel exercise
group dropped out of treatment due to being unable to
regularly participate. There was no possibility of replace-
ment because two months had passed since the starting
of the exercises and due to the absence of another eligible
sample. Finally, a total of 72 patients completed the study
(Figure 1).
3.2. Procedure
Patients of both intervention groups had participated
in exercise sessions that were held in the outpatient clinic
of Shahid Beheshti Hospital during three exercise sessions,
on alternate days, for a total span of 12 weeks. Each session
lasted for about 60 minutes (Two 30-minute sessions with
15-minute rest intervals). The vestibular rehabilitation ex-
ercise was performed based on the protocols established
by Cawthorne and Cooksey. On the basis of the aforemen-
tioned protocols, it was performed in both the sitting and
the upright position; it was performed once with open eyes
and then, the exercise was carried out with closed eyes (30,
31). The protocol is described in details in Appendix 1 in
Supplementary File.
Patients in the Frenkel group performed exercises
based on protocols obtained from a previous study (32).
Frenkel exercise was performed in the following different
positions, including lying down, sitting up, and standing
(Appendix 2 in Supplementary File for details). Patients in
the control group only received routine care.
3.3. Measures
Patients’ fatigue was assessed by the Fatigue Impact
Scale (FIS) before the exercises, six and twelve weeks after
the start of exercises. The FIS was designed by Fisk et al.
to assess fatigue in MS patients (33). This scale contains
40 items, and assesses the functional limitations of peo-
ple in subscales of categories: Cognitive (10 items), phys-
ical (10 items), and psychosocial (20 items). Items of the
cognitive subscale measure concentration, memory, think-
ing, and the organization of thoughts. The physical sub-
scale reflects a person’s motivation, effort, tolerance, and
harmony. The psychosocial subscale evaluates the impact
of fatigue upon isolation, emotions, workload, and coping.
Items are rated on a five-point Likert scale. Each item is
graded from zero (no problem) to four (extreme problem),
and the range of the total fatigue score is 0 to 160. The va-
lidity and the reliability of the Persian version of FIS have
been confirmed previously (34).
Iran Red Crescent Med J. In Press(In Press):e68913.
3.4. Data Analysis
The collected data were analyzed using descriptive
and inferential statistics, employing the IBM SPSS Statis-
tics Software for Windows, version 19.0 (IBM Corp., Ar-
mork, N.Y. USA) by considering a confidence interval of
95%. At first, the distribution of fatigue was assessed by
the Kolmogorov-Smirnov Z-test. It had a normal distribu-
tion, therefore, the results of the parametric tests were re-
ported for analysis. A Repeated-Measure Analysis of Vari-
ance (ANOVA) was used to compare the mean score of fa-
tigue among the three groups. Since the assumption of
Mauchly’s test of sphericity of repeated measures ANOVA
test was violated, Greenhouse Geisser epsilon correction
was reported. The mean difference of fatigue was signif-
icant; therefore, pairwise comparison of the mean differ-
ence was conducted by Bonferroni post hoc test. Because
there were three groups in this study, the significance level
was equal to or less than 0.015 (α/3) in the pairwise com-
parison.
4. Results
Seventy-two patients aged between 18 and 48 years
(Mean: 32.7 ± 7.4) participated in this study. About 56
(77.8%) patients were female, 68 (94.4%) patients had the
relapsing-remitting type of MS, and four (5.6 %) patients
had primary and secondary progressive type of MS. Forty-
two (58.4%) patients used the interferon Beta-1a drug, 16 pa-
tients (22.2%) used the interferon Beta-1b, and the other pa-
tients used other drugs. The mean body mass index, the
age of disease onset, and the duration of illness were 23.4 ±
2.3 kg/m2 , 27.6 ± 7.2 years, and 60.5 ± 37.4 months, respec-
tively. No statistically significant difference was observed
among the three groups by the demographic variables (P =
0.7).
Repeated measures ANOVA test showed statistically
significant differences in the mean the total fatigue scores
and its subscales in terms of time/group among the three
groups (P < 0.05) (Table 1). Pairwise comparison of the
mean difference of the total fatigue and its subscales
scores showed that there were statistically significant dif-
ferences between the three groups at the baseline and
six weeks after starting the intervention (P > 0.05), ex-
cept in case of vestibular rehabilitation and in the control
group, in which pair-wise comparison for six weeks post-
intervention was significant (P = 0.009). A statistically sig-
nificant difference was observed between the vestibular re-
habilitation and the Frenkel groups at the end of the in-
tervention (P = 0.007). Comparing the FIS subscales be-
tween the vestibular rehabilitation and the Frenkel groups
3
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Karami F et al.

Assessed for eligibility (n = 120)

Excluded (n = 45)
Not Meeting Inclusion Criteria (n = 38)
10 = Not able to stand independently for 30
seconds
First data gathering (before intervention) 11 = Not able to walk independently a
Enrollment distance of 6 meters
5 = Have a Fatigue Impact Scale (FIS) scores
of less than 54 or more than 107
8 = Have a Berg Balance Scale (BBS) scores
of less than 21 or more than 40
4 = Disease affecting the central nervause
system other than multiple sclerosis
Randomized (n = 75) Declined to Participate (n = 7)

Allocation

Vestibulur rehabilitation (n = 25) Frenkel Group (n = 25) Control Group (n = 25)

Recived allocated intervention Received allocated intervention Received allocated intervention
(n = 25) (n = 25) (n = 25)
Did not receive allocated Did not receive allocated Did not receive allocated
intervention (n = 0) intervention (n = 0) intervention (n = 0)

Follow-Up

Second data gathering ( six weeks after baseline)

Follow-Up

Lost to follow-up after eight weeks
intervention (n = 1)
Unable to regularly participation
(n = 1)
Lost to follow-up after eight weeks Lost to follow-up (n = 0)
intervention (n = 2)
Unable to regularly participation
(n = 1)
Disease relapses (n = 1)

Follow-Up

Third data gatherug (twelve weeks After baseline)

Analysis

Analyzed (n = 24) Analyzed (n = 23) Analyzed (n = 25)

Figure 1. The study design

showed that there was no difference in the cognitive sub-
scale (P = 0.1); significant differences were, however, ob-
served by the physical (P = 0.001) and the psychosocial sub-
scales (P = 0.01) at the end of the intervention (Table 2).
There was a statistically significant reduction in the
mean score of total fatigue of the two exercise groups; in
other words, both interventions reduced fatigue in the pa-
tients. However, the reduction of fatigue was statistically
significant in vestibular rehabilitation exercise in compar-
ison with Frenkel exercise. The mean total fatigue in the
vestibular rehabilitation group was 92.7 ± 12.8, 78.2 ± 15.2,
and 63.4 ± 14.6, respectively, before the interventions, and
six and twelve weeks after it; also, in the Frenkel group,
the mean fatigue at these aforementioned times was 89.6
± 16.4, 84.3 ± 16.6, and 78.6 ± 16.3, respectively. Fatigue
was not reduced in the control group, and it gradually in-
creased according to the FIS score from 89.2 ± 15.5 at base-
line to 96.5 ± 18 at the end of the study.

4 Iran Red Crescent Med J. In Press(In Press):e68913.

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Karami F et al.
Furthermore, a difference in the mean scores of to-
tal fatigue was observed in both the vestibular rehabilita-
tion and the Frenkel group in comparison with the control
group, at the end of the intervention (P = 0.001). The dif-
ferences in the mean scores of total fatigue in the vestibu-
lar rehabilitation group in comparison with the control
group, six and twelve weeks after intervention, were 14.1,
and 33.1, respectively; in the Frenkel group, however, the
differences were 8 and 17.9, respectively.
Additionally, the findings showed that there was a bal-
ance in the improvement of exercise groups after the in-
tervention (P = 0.001). Therefore, correlational analyses
were performed to test the relationship between fatigue
and balance. The Pearson correlation coefficient test was
used for the analysis of associations; a negative correlation
between fatigue and balance was reported at the end of the
intervention phase (r = -0.5, P < 0.001).
5. Discussion
The effectiveness of vestibular rehabilitation and
Frenkel exercise on fatigue were compared among MS
patients in the present study. The results showed that
fatigue decreased in MS patients following the mentioned
exercises and the vestibular rehabilitation exercise was
more effective in decreasing fatigue in comparison to the
Frenkel exercise.
Consistent with available studies about the effective-
ness of exercise therapy, Kierkegaard et al. (35), and Giesser
(36) reported reduced fatigue in MS patients following dif-
ferent exercise therapies. How exercises decrease fatigue
in MS patients is still poorly understood, however, the rea-
son behind this decrease may be due to the effect of exer-
cises in increasing energy reserves and enhancing neuro-
biological processes (37). In addition, environmental phys-
iology changes, such as increasing oxygen and blood sup-
ply to muscles that occur after exercise, may be effective in
reducing fatigue (38). In contrast to the current findings,
a study by Pilutti et al. showed that supported treadmill
training had a low impact on decreasing fatigue in MS pa-
tients (39). Furthermore, Newman et al. found that the
level of fatigue in MS patients was unchanged after aerobic
training (40). Results contradicting the aforementioned
phenomenon may be due to the type and the duration of
exercises, methodology of the studies, and the various fa-
tigue assessment tools.
Patients in the current study experienced a reduction
in fatigue following both exercise programs in comparison
to the control group. The reason for this finding may be
due to the effect of these exercises on improving the pa-
tient’s balance; therefore, they can reduce fatigue. As in
Iran Red Crescent Med J. In Press(In Press):e68913.
this study, there was a correlation between increasing bal-
ance and decreasing fatigue. The effect of vestibular reha-
bilitation exercise on improving various symptoms, such
as dizziness, quality of life (41), and balance (42) in MS pa-
tients and also reducing the risk of falls in older adults (43)
have been reported. On the other hand, the positive ef-
fect of Frenkel exercise for elderly individuals as well as for
patients with neurological disorders associated with im-
balances was reported in a study by Makuła (44). Increas-
ing fatigue in the control group of the current study in-
dicated that the lack of a planned exercise program may
lead to worsening of symptoms in patients with MS. The
other result of the current study showed that vestibular re-
habilitation exercise was more effective than Frenkel exer-
cise. This finding had a number of similarities with the re-
sults of Hebert et al., they showed that MS patients, who
participated in vestibular rehabilitation exercise experi-
enced decreased fatigue than the exercise control group
and the wait listed control group (45). Vestibular rehabil-
itation exercises can affect three balance centers (i.e. the
cerebellum, vestibular, and the visual system) at the same
time (46, 47). This can result in improving balance, and
subsequently, further fatigue reduction. Frenkel exercise
may only improve the cerebellum function for coordinat-
ing movements (48).
According to another finding of the current study,
there were differences in the reductions of fatigue in the
physical and psychosocial subscales between the two exer-
cises, yet no difference was observed in the cognitive sub-
scale. The treatment of cognitive fatigue is very complex
as a variety of factors may be involved in its origin (49),
and it has a negative effect on cognitive tasks, physical con-
ditions, and social functions (50). Therefore, treatments
should target to improve cognitive fatigue in MS patients.
Although the findings of this study are related to the
positive effects of vestibular rehabilitation and Frenkel ex-
ercise on fatigue in MS patients, some limitations need
to be considered. The first limitation was the data collec-
tion tool. Although the reliability and the validity of the
FIS has been approved in Persian, being a self-report ques-
tionnaire in addition to the subjective nature of fatigue
might have an influence on the accuracy of patients to an-
swer questions. Therefore, further studies are suggested
to examine the effectiveness of these exercises with other
fatigue measures, particularly with more objective tools.
The second limitation of this study was that the majority
of patients in this study had the relapsing-remitting type
of MS. Since fatigue may be different in the four types of
MS (relapsing-remitting, secondary-progressive, primary-
progressive, and progressive-relapsing), further studies
are recommended to investigate the effects of the men-
tioned exercises on fatigue in MS patients with the other
5
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Karami F et al.
forms of the disease.
In summary, the current study showed that both
vestibular rehabilitation and Frenkel exercise could re-
duce fatigue at the end of the exercises, however, there
were significant differences in the effects of these exer-
cises. In other words, the vestibular rehabilitation exercise
is more effective than the Frenkel exercise in reducing fa-
tigue. Finally, the researchers suggest that these exercises
should be performed alongside medication in MS patients
owing to their various benefits, such as ease of learning,
low cost, and non-invasive nature.
Supplementary Material
Supplementary material(s) is available here [To read
supplementary materials, please refer to the journal web-
site and open PDF/HTML].
Acknowledgments
The authors wish to thank all MS patients for their kind
participation in this research study. The researchers, also
thank the Office of Vice Chancellor for Research at Yasuj
University of Medical Sciences, and those, who guided and
helped the study.
Footnotes
Authors’ Contribution: Fatemeh Karami: designing
the research, sampling, allocating samples to the study
groups, implementation of the intervention, collecting
data, and compiling the article; Ardashir Afrasiabifar:
monitoring of intervention, analysis of data, and compil-
ing the article, and Shahla Najafi Doulatabad: collecting
data.
Conflict of Interests: None declared.
Ethical Considerations: The Ethics Committee Approval
Number: ir.yums.REC.1394.180.
Funding/Support: This study was supported by a Master
thesis grant from the Deputy of Research and Technology
of the Yasuj University of Medical Sciences, Iran.
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8
Table 1. Between Group Comparisons of Mean Scores of Patients’ Fatiguea

Groups Vestibular Rehabilitation Frenkel Control P Value

(Time/Group)

Change Scores Change Scores Change Scores

95% Confidence Interval for Mean 95% Confidence Interval for Mean 95% Confidence Interval for Mean Repeated
from from from
Fatigue/Times Mean ± SD Mean ± SD Mean ± SD Measures
Baseline, Baseline, Baseline,
ANOVA
Mean (SD) Lower Bound Upper Bound Mean (SD) Lower Bound Upper Bound Mean (SD) Lower Bound Upper Bound

Total fatigue

T1 92.7 ± 12.8 - 86.6 98.8 89.6 ± 16.4 - 83.4 95.8 89.2 ± 15.5 - 83.2 95.1

T2 78.2 ± 15.2 -14.5 (3.4) 71.6 84.8 84.3 ± 16.6 -5.3 (2.4) 77.6 91 92.3 ± 16.5 3.1 (2.2) 85.9 98.8 0.001

T3 63.4 ± 14.6 -29.3 (4.30 56.8 70.1 78.6 ± 16.3 -11 (2.1) 71.7 85.4 96.5 ± 18 7.3 (4.5) 90 103.1

Cognitive subscale

T1 20.4 ± 3.5 - 18.8 21.9 22.5 ± 4.1 - 20.9 24.1 19.7 ± 4 - 18.2 21.3

T2 18.7 ± 3.3 -1.7 (1.4) 17.4 20.1 20.2 ± 3.5 -2.3 (1.4) 18.8 21.6 20.8 ± 3.6 1.1 (1.3) 19.5 22.2 0.001

T3 16.3 ± 3.4 -4.1 (2.2) 14.8 17.7 17.9 ± 3.6 -4.6 (1.9) 16.4 19.4 22 ± 3.6 2.3 (1.9) 20.5 23.4

Physical subscale

T1 28.3 ± 4.8 - 26 30.7 27.8 ± 5.5 - 25.4 30.2 26.6 ± 6.9 - 24.3 29

T2 21.2 ± 4.7 -7.1 (2.4) 18.9 23.6 25.9 ± 5.3 -1.9 (1.7) 23.5 28.3 27.4 ± 6.7 0.8 (1.1) 25.1 29.7 0.01

T3 14.4 ± 4.6 -13.9 (2.7) 12.3 16.6 23.8 ± 4.5 -4 (1.9) 21.6 26 28.8 ± 6.4 2.2 (1.7) 26.7 30.9
Karami F et al.

Psychosocial subscale

T1 44 ± 9.7 - 39.7 48.3 39.3 ± 11.5 - 34.9 43.6 42.8 ± 10.1 - 38.6 47

T2 38.2 ± 10 -5.8 (2.3) 33.9 42.5 38.2 ± 11.3 -1.1 (1.2) 33.7 42.6 44.1 ± 10.7 1.3 (1.2) 39.8 48.3 0.001

T3 27.9 ± 6.6 -16.1 (3.8) 23.8 32.1 36.9 ± 11.3 -2.4 (1.3) 32.7 41.1 45.8 ± 11.5 3 (2.4) 41.7 49.8
Uncorrected Proof

a T1, baseline; T2, six weeks after starting the intervention; T3, twelve weeks after starting the intervention.

Iran Red Crescent Med J. In Press(In Press):e68913.

 Table 2. Paired Comparison of the Mean Differences of Patients’ Fatigue by Time/Group

Paired Comparison Vestibular Rehabilitation-Frenkel Vestibular Rehabilitation-Control Frenkel-Control

95% CI for Mean Difference 95% CI for Mean Difference 95% CI for Mean Difference
Fatigue/Times Mean Difference P Valuea Mean Difference P Valuea Mean Difference P Valuea
Lower Bound Upper Bound Lower Bound Upper Bound Lower Bound Upper Bound

Total fatigue

T2 -6.1 -17.6 5.4 0.4 -14.1 -25.4 2.8 0.009 -8 -19.4 3.4 0.2

T3 -15.2 -26.8 -3.4 0.007 -33.1 -44.6 -21.6 0.001 -17.9 -29.6 -6.3 0.001

Cognitive subscale

T2 -1.5 -3.9 1 0.1 -2.1 -4.5 0.3 0.09 -0.6 -3.1 1.8 0.8

T3 -1.6 -4.2 0.9 0.1 -5.7 -8.1 -3.2 0.001 -4.1 -6.6 -1.5

Physical subscale

T2 -4.7 -8.7 -0.6 0.01 -6.2 -10.1 -2.1 0.001 -1.5 -5.5 2.5 0.6

T3 -9.4 -13.1 -5.5 0.001 -14.4 -18 -10.6 0.001 -5 -8.8 -1.3 0.005

Psychosocial
subscale

T2 0 -7.6 7.6 0.9 -5.9 -13.3 1.6 0.1 -5.9 -13.5 1.7 0.1

T3 -9 -16.1 -1.7 0.01 -17.9 -24.9 -10.7 0.001 -8.9 -16 -1.7 0.009

Iran Red Crescent Med J. In Press(In Press):e68913.

Abbreviation: CI, confidence interval.
a Post Hoc.
Karami F et al.
Uncorrected Proof